scholarly journals Evaluation of maternal and fetal outcome in pregnancies complicated by jaundice-an observational study

2021 ◽  
Author(s):  
Ruchi Kishore ◽  
Neha Thakur ◽  
Mitali Tuwani
Keyword(s):  
Mortality Rate ◽  
Observational Study ◽  
Maternal Mortality ◽  
Viral Hepatitis ◽  
Hellp Syndrome ◽  
Fetal Outcome ◽  
Maternal Outcome ◽  
Fetal Mortality ◽  
Maternal Mortality Rate ◽  
In Pregnancy

Background: The spectrum of jaundice in pregnancy varies from a benign condition with good maternal and fetal outcome to a severe form resulting in liver failure and maternal and fetal mortality. Jaundice may complicate 3-5% of pregnancies. Present study was aimed to analyze the cause, course and impact of jaundice during pregnancy so as to have better understanding and hence better feto-maternal outcome. The present study aimed to analyze the various causes of hepatic dysfunction in pregnancy, maternal and fetal outcome in pregnancies complicated by jaundice and various hematological and liver function variables for predicting maternal and fetal outcome.Methods: The present study was an observational study conducted in the department of obstetrics and gynecology, Pt. JNM medical college and associated Dr. BRAM hospital, Raipur (CG) over period of 2 year from September 2018 to September 2020.Results: Total 0.72% pregnancies were complicated by jaundice. HELLP syndrome was the commonest cause of jaundice in pregnancy (36.7%), followed by viral hepatitis (32.7%). Hepatitis E was the most common type of viral hepatitis (91.8%). Hemolytic jaundice presented with best maternal outcome (maternal mortality rate 8.6%). Worst maternal outcome was seen in AFLP (maternal mortality rate 100%). Best fetal outcome was seen in viral hepatitis (live birth rate 67.6%), whereas worst noted with AFLP (fetal death rate 66.6%). Higher total serum bilirubin, higher serum AST, anemia and deranged INR had significant correlation with maternal mortality.Conclusions: HELLP syndrome and viral hepatitis are preventable causes of jaundice yet it contributed to significant proportion of maternal deaths in 26.5 and 18.5% cases respectively. AFLP is often under diagnosed and had a fulminant course in pregnancy causing maternal and fetal mortality.

scholarly journals Pregnancy Outcome in Viral Hepatitis

2013 ◽  
Vol 5 (2) ◽  
pp. 60-63
Author(s):  
Sulbha Joshi ◽  
Varsha Kose
Keyword(s):  
Viral Hepatitis ◽  
Pregnancy Outcome ◽  
Hepatitis E ◽  
Fetal Outcome ◽  
Research Centre ◽  
Premature Delivery ◽  
Fetal Mortality ◽  
Obstetrics And Gynecology ◽  
Major Public Health Problem ◽  
In Pregnancy

ABSTRACT Introduction Hepatitis in pregnancy is an important medical disorder seen more often in developing countries than in developed ones. Viral hepatitis is a major public health problem in India. Hepatitis in pregnancy is commonly associated with abortion, premature delivery, postpartum hemorrhage, coagulation defect, obstetric shock, coma, death and increased perinatal mortality and morbidity. This study was carried out to know the effect of viral hepatitis on pregnancy and to study its maternal and fetal outcome. Materials and methods This prospective clinical study was conducted in the Department of Obstetrics and Gynecology NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Nagpur, from January 2010 to December 2012. All the antenatal cases attended Obstetrics and Gynecology Department were investigated for HBsAg and looked for any symptoms and signs suggesting hepatitis like fever, jaundice, nausea, vomiting. If present, they were admitted and further investigated to detect viral hepatitis. Patients were counseled for follow-up and strict hospital delivery. Patients with viral hepatitis were analyzed for the effect on pregnancy, maternal and fetal outcome. Results There were total 30 cases of viral hepatitis 24 (80%) cases were HBsAg positive, but all were asymptomatic 6 (20%) cases were hepatitis E positive. No HAV, HCV, HDV and hepatitis G infected cases were detected in our study. Maternal and fetal morbidity was significantly higher in hepatitis E infected women. Fetal mortality was observed in one case. Conclusion Pregnancy with viral hepatitis requires early diagnosis, hospitalization and treatment. In the present study hepatitis E was found to be the chief etiological agent associated with increased maternal morbidity, and high fetal morbidity and mortality. How to cite this article Kose V, Joshi S. Pregnancy Outcome in Viral Hepatitis. J South Asian Feder Obst Gynae 2013;5(2): 60-63.

scholarly journals EXPRESS: Pulmonary arterial hypertension in pregnancy – a systematic review of outcomes in the modern era

2021 ◽  
pp. 204589402110136
Author(s):  
Ting Ting Low ◽  
Nita Guron ◽  
Robin Ducas ◽  
Kenichiro Yamamura ◽  
Pradeepkumar Charla ◽  
...  
Keyword(s):  
Pulmonary Arterial Hypertension ◽  
Mortality Rate ◽  
Arterial Hypertension ◽  
Maternal Mortality ◽  
Post Partum ◽  
Systolic Pressure ◽  
Pulmonary Artery Systolic Pressure ◽  
Maternal Mortality Rate ◽  
Pulmonary Arterial ◽  
In Pregnancy

Background: Pregnancy is hazardous with pulmonary arterial hypertension (PAH), but the risks may have improved in recent years. We sought to systematically evaluate PAH and pregnancy-related outcomes in the last decade. Methods: We searched for articles describing outcomes in pregnancy cohorts published between 2008-2018. 3658 titles were screened and 13 studies included for analysis. Pooled incidences and percentages of maternal and perinatal outcomes were calculated.  Results: Out of 272 pregnancies, 214 pregnancies advanced beyond 20 gestational weeks. The mean maternal age was 28±2 years, mean pulmonary artery systolic pressure on echocardiogram was 76±19mmHg. Aetiologies include idiopathic PAH 22%, congenital heart disease 64%, and others 15%. Majority (74%) had good functional class I/II. Only 48% of women received PAH-specific therapy. Premature deliveries occur in 58% of pregnancies at mean of 34±1 weeks, most (76%) had caesarean section. Maternal mortality rate was 12% overall (n=26); even higher for idiopathic PAH aetiology alone (20%). Reported causes of death included right heart failure, cardiac arrest, PAH crises, pre-eclampsia and sepsis. 61% of maternal deaths occur at 0-4 days post-partum. Stillbirths rate was 3% and neonatal mortality rate 1%. Conclusions: PAH in pregnancy continues to be perilous with high maternal mortality rate. Continued prospective studies are needed.

scholarly journals A study of fetomaternal outcome of hepatic disorders in pregnancy

2019 ◽  
Vol 8 (3) ◽  
pp. 1182
Author(s):  
Mahima Jain ◽  
Himani Thaker
Keyword(s):  
Maternal Mortality ◽  
Viral Hepatitis ◽  
Rural Areas ◽  
Acute Viral Hepatitis ◽  
Tertiary Care ◽  
Birth Asphyxia ◽  
Fetal Outcome ◽  
The Body ◽  
Mortality And Morbidity ◽  
In Pregnancy

Background: Liver is a vital organ to maintain physiology of the body and supports every organ of the body. Its proper functioning during pregnancy is essential for a good maternal and fetal outcome. The study analyses the causes and fetomaternal outcome in pregnancies with jaundice and suggests measures to reduce morbidity and mortality.Methods: This is a one-year prospective study in a tertiary care institute during which 7165 deliveries are conducted. Total 55 cases of Jaundice with pregnancy are identified and studied for clinical, biochemical profile, etiology and maternal and fetal outcome. 8 maternal deaths are reported amongst this study group.Results: In this study 55 cases of hepatic disorders in pregnancy are studied. The age group reported is 21-29 years. Majority 72% cases belong to rural areas and 85% in lower socioeconomic class. 96.3% patients were in the third trimester of pregnancy. Most common etiology of hepatic disorders in pregnancy is acute viral hepatitis followed by intrahepatic cholestasis of  pregnancy and preeclampsia and HELLP syndrome. In acute viral hepatitis 81% patients were hepatitis E positive. Most common complication are DIC followed by hemorrhagic shock and subsequently AKI and septicemia. 77.7% babies were born alive and 30.9% NICU admission due to severe birth asphyxia and prematurity. Of these 16.6% died in neonatal period. Maternal mortality in 14.5% patients due to viral hepatits, HELLP and septicemia.Conclusions: Jaundice in pregnancy is a rare medical disorder and deadly combination affecting maternal and fetal outcome. Earl detection and timely intervention with multidisciplinary approach including obstetrician, neonatologist, intensivist and skilled nursing care can help to reduce maternal mortality and morbidity.

scholarly journals HIPERTENSI PADA KEHAMILAN: ANALISIS KASUS

2014 ◽  
Vol 8 (1) ◽  
pp. 30-35
Author(s):  
Imami N. Rachmawati
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
Maternal Death ◽  
Gender Issue ◽  
Case Description ◽  
Maternal Mortality Rate ◽  
Hypertensive Disorders ◽  
Big City ◽  
Hypertensive Disorders In Pregnancy ◽  
In Pregnancy

AbstrakArtikel ini menggali aspek-aspek yang berkontribusi terhadap Angka Kematian Ibu (AKI). Pemaparan sebuah kasus hipertensi dalam kehamilan yang terjadi di salah satu kota besar akan menekankan bahwa ada dua penyebab kematian ibu yaitu penyebab langsung dan tidak langsung. Artikel ini mendiskusikan isyu persamaan jender yang berhubungan dengan AKI dan juga membahas program-program penurunan AKI saat ini. Sudahkah semuanya memandang perempuan sebagai individu yang holistik? Jika belum sudah saatnyalah kita mempertimbangkannya untuk hasil yang lebih baik. AbstractThis article explores what aspects contributing the maternal mortality rate (MMR). A case description regarding hypertensive disorders in pregnancy that happen in a big city will emphasize that cause of maternal death is direct and indirect factors. This article also discusses the gender issue due to MMR. Through this article we need to re-thinking regarding current programs to reduce MMR, have they view women as holistic individual.

FAKTOR– FAKTOR YANG BERHUBUNGAN DENGAN KEJADIAN ANEMIA PADA IBU HAMIL DI PUSKESMAS TALANG RATU PALEMBANG TAHUN 2014

2019 ◽  
Vol 4 (2) ◽  
Author(s):  
Yuhemy Zurizah Yuhemy Zurizah
Keyword(s):  
Mortality Rate ◽  
Health Service ◽  
Maternal Mortality ◽  
Pregnant Women ◽  
Health Center ◽  
Significant Relationship ◽  
World Health ◽  
Chi Square ◽  
Cross Sectional ◽  
Maternal Mortality Rate

  ABSTRACT Maternal Mortality Rate is a barometer of mother health service in a country. At this time maternal mortality rate in Indonesia is still very high. Indonesia Demography Survey on 2007, maternal mortality rate is about 28 per 100.000 of live births. The direct cause of maternal mortality in Indonesia as well as in the other country is hemorraghe (25%), sepsis (15%), eklampsia (12%), abstructed labor (8%). World Health Organization (WHO), 35-37% of pregnant women in developing coutries get anemy. Causing factor’s of anemy on pregnant women is age of pregnant, parity, economi socio, job, education, and nutritional status. Purpose of this research is to know the associated factors with incidence of anemy on pregnant women at the Health Center Talang Ratu Palembang in 2014. This research use analytic survey method with “cross sectional” approach. Population in this research is all of preganant women in medical treatment at Talang Ratu Palembang in 2014. Sample taking in this research with non random samplingmethod and accidental sampling technic. Analysis with univariatly and bivariatlywith Chi Square Statistic test with significant level α 0,05. The result of this research show that from 35 respondent there is (48,6%) respondent with anemy, high–risk age (28,6%), high parity (60,0%) and low economi socio (37,1%). This result show that there is significant relationship between age with incidence of anemy on pregnant women at the health center Talang Ratu Palembang in 2014 with p value0,027, there is significant relationship between parity with incidence of anemy on pregnant women at the health center Talang Ratu Palemabang in 2014 with p value0,023, and there is significant relationship between economi socio with incidence of anemy on pregnant women at the health center Talang Ratu Palembang in 2014 with p value0,026. Of the result, the author hope that health service worker at Talang Ratu health center can improve health service to pregnant women and often giving information about anemy on pregnant and nutritional for pregnant women during pregnancy.     ABSTRAK Angka Kematian Ibu (AKI) merupakan barometer pelayanan kesehatan ibu di suatu negara. Pada saat ini angka kematian ibu di Indonesia masih sangat tinggi. Menurut Survey Demografi dan Kesehatan Indonesia (SDKI) tahun 2007, angka kematian kematian ibu adalah 28 per 100.000 kelahiran hidup. Penyebab langsung kematian ibu di Indonesia seperti halnya Negara lain adalah perdarahan (25%), sepsis (15%), eklampsi (12%), partus lama (8%). Menurut World Health Organization (WHO), 35-37% ibu hamil di negara berkembang dan 18% di negara  maju mengalami anemia. Faktor penyebab terjadinya anemia pada ibu hamil secara tidak langsung adalah umur ibu, paritas, sosial ekonomi, pekerjaan, pendidikan, jarak kehamilan, dan status gizi.Tujuan penelitian ini adalah untuk mengetahui faktor - faktor apa saja yang berhubungan dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014. Penelitian ini menggunakan metode survey analitikdengan pendekatan cross sectional. Populasi dalam penelitian ini adalah seluruh ibu hamil yang berobat di Puskesmas Talang Ratu Palembang Tahun 2014. Pengambilan sampel pada penelitian ini dengan metode non random sampling dengan teknik Accidental sampling. Analisis dilakukan secara univariat dan bivariat. Dengan uji statistik chi square tingkat kemaknaan α 0,05. Hasil penelitian menunjukkan dari 35 responden terdapat (48,6%) responden yang anemia, umur yang beresiko  tinggi (28,6%), paritas tinggi (60,0%), dan sosial ekonomi rendah (37,1%). Hasil penelitian ini menunjukkan ada hubungan yang bermakna antara umur dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan  p value0,027,  ada hubungan bermakna antara paritas dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan p value0,023 dan ada hubungan yang bermakna antara sosial ekonomi dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan p value0,026. Dari hasil penelitian ini penulis berharap petugas kesehatan di Puskesmas Talang Ratu Palembang meningkatkan pelayanan kesehatan pada ibu hamil dan lebih sering melaksanakan penyuluhan anemia pada kehamilan dan nutrisi yang baik bagi ibu hamil.    

scholarly journals PERBANDINGAN REGRESI ZERO INFLATED POISSON (ZIP) DAN REGRESI ZERO INFLATED NEGATIVE BINOMIAL (ZINB) PADA DATA OVERDISPERSION (Studi Kasus: Angka Kematian Ibu di Provinsi Bali)

2016 ◽  
Vol 5 (4) ◽  
pp. 133
Author(s):  
NI PUTU PREMA DEWANTI ◽  
MADE SUSILAWATI ◽  
I GUSTI AYU MADE SRINADI
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
Regression Models ◽  
Negative Binomial ◽  
Mean Value ◽  
Response Variable ◽  
Maternal Mortality Rate ◽  
Excess Zeros ◽  
Zero Values ◽  
Independent Variable

Poisson regression is a nonlinear regression which is often used for count data and has equidispersion assumption (variance value equal to mean value). However in practice, equidispersion assumption is often violated. One of it violations is overdispersion (variance value greater than the mean value). One of the causes of overdipersion is excessive number of zero values on the response variable (excess zeros). There are many methods to handle overdispersion because of excess zeros. Two of them are Zero Inflated Poisson (ZIP) regression and Zero Inflated Negative Binomial (ZINB) regression. The purpose of this research is to determine which regression models is better in handling overdispersion data. The data that can be analyzed using the ZIP and ZINB regression is maternal mortality rate in the Province of Bali. Maternal mortality rate data has proportion of zeros value more than 50% on the response variable.  In this research, ZINB regression better than ZIP regression for modeling maternal mortality rate. The independent variable that affects the number of maternal mortality rate in the Province of Bali  is the percentage of mothers who carry a pregnancy visit, with ZINB regression models and . 

scholarly journals Two year review of maternal mortality at a tertiary care hospital of GMERS, Valsad, Gujarat, India

2018 ◽  
Vol 7 (6) ◽  
pp. 2283
Author(s):  
Darshna M. Patel ◽  
Mahesh M. Patel ◽  
Vandita K. Salat
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
Rural Areas ◽  
Tertiary Care ◽  
Maternal Mortality Ratio ◽  
Care Hospital ◽  
Maternal Deaths ◽  
Maternal Mortality Rate ◽  
Live Births ◽  
Mortality Ratio

Background: According to the WHO, 80 of maternal deaths in developing countries are due to direct maternal causes such as haemorrhage, hypertensive disorders and sepsis. These deaths are largely preventable. Maternal mortality ratio (MMR) in India is 167/100,000 live births.Methods: This retrospective observational study was conducted at GMERS, Valsad. Data regarding maternal deaths from January 2016 to December 2017 were collected and analyzed with respect to epidemiological parameters. The number of live births in the same period was obtained from the labour ward ragister. Maternal mortality rate and Mean maternal mortality ratio for the study period was calculated.Results: The mean Maternal mortality rate in the study period was 413.3/100,000 births. The maternal mortality ratio (MMR) in India is 167/100,000 live births. More than half of maternal deaths were reported in multiparous patients. More maternal deaths were observed in women from rural areas (67.3%), unbooked patients (73.3%) and illiterate women (65.3%). Thirty six (69.3%) maternal death occurred during postpartum period. Most common delay was first delay (60.0%) followed by second delay (40.0%). Postpartum haemorrhage (28.8%), preeclampsia (17.3%), sepsis (13.46%) were the major direct causes of maternal deaths. Indirect causes accounted for one third of maternal deaths in our study. Anemia, hepatitis and heart disease were responsible for 13.4%, 5.7%, and 1.9% of maternal deaths, respectively.Conclusions: Majority of maternal deaths are observed in patients from rural areas, unbooked, and illiterate patients. Hemorrhage, eclampsia and sepsis are leading causes of maternal deaths. Most of these maternal deaths are preventable if patients are given appropriate treatment at periphery and timely referred to higher centers.

scholarly journals THE EFFECT OF RED SESBANIA (SESBANIA GRANDIFLORA L.PERS) LEAVES EXTRACT ADMINISTRATION ON THE DECREASE OF LEUKOCYTE LEVEL IN POST-PARTUM MICE (MUS MUSCULUS) INFECTED WITH STREPTOCOCCUS AGALACTIAE

2018 ◽  
Vol 2 (01) ◽  
pp. 6-11
Author(s):  
HEPPY RINA MARDIANA ◽  
Surya Mustika Sari ◽  
YUFI ARIS LESTARI ◽  
ANIK SUPRIANI ◽  
NANIK NUR ROSYIDAH ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
Mus Musculus ◽  
Streptococcus Agalactiae ◽  
Post Partum ◽  
Organ Injury ◽  
Control Group ◽  
Maternal Mortality Rate ◽  
Treatment Groups ◽  
Infection Incidence

Introduction: Maternal Mortality Rate (MMR) is indicator of public health degree. The cause of maternal mortality is postpartum infection. Streptococcus agalactiae bacterium contributes to postpartum infection incidence through vaginal or reproductive organ injury. Infection incidence is characterized with the increased level of leukocyte. The treatment of post-partum infection is done by administering antibiotics. Red sesbania leaves contains active substance that can inhibit the microbial growth. Objective: This research aimed to find out the effect of red sesbania leaves extract administration as antimicrobial agent to decrease leukocyte level in post partum mice (Mus musculus) infected with Streptococcus agalactiae. Method: The method employed was true experimental one with post test control group design, by dividing postpartum mice into 4 groups: one control group and three treatment groups at doses of 125 mg/kgBW, 250 mg/kgBW, and 500 mg/kgBW. All 0-12 hour post partum mice were inoculated with Streptococcus agalactiae bacterium. The administration of 1 ml red sesbania leaves extract in treatment group was conducted 2 hours after the bacterial administration at doses of 125 mg/kgBW, 250 mg/kgBW, and 500 mg/kgBW. Result: The result of analysis shows p < 0.05, indicating that the decrease of leukocyte level in all treatment groups (P1, P2, P3). Conclusion: Red sesbania leaves extract has antimicrobial activity that can reduce leukocyte level, thereby can be used as an alternative therapy to decrease maternal mortality rate due to post-partum infectin. KEYWORDS Red sesbania leaves extract, postpartum mice, leukocyte level, Streptococcus agalactiae.

scholarly journals Determinants of Maternal Mortality Rate in The Kyrgyz Republic Regions

2017 ◽  
Author(s):  
Nurbek Madmarov ◽  
Metin Bayrak
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
Women’S Health ◽  
Women's Health ◽  
Fixed Effects ◽  
World Health ◽  
Kyrgyz Republic ◽  
Maternal Mortality Rate ◽  
The World ◽  
Determinants Of Maternal Mortality

Population is an important factor in development of a country. As a constraint, not only the size of the population is important but also its quality in the development process. Women’s health is considered all over the world and the data about this aspect is published by the World Health Organization annually. Among others maternal mortality rate is one of the major problems affecting women’s health and population. Everyday 830 women die due to the problems related to pregnancy and childbirth in the world. While this number is relatively lower in the developed countries, it is higher in the underdeveloped and developing countries. In addition, the maternal mortality rate in the Caucasus and Central Asia ranks in the worst third in the world. In the Kyrgyz Republic, this rate is 82.083333 per 10000 live births which is the worst in the region. Therefore, it is among one of the countries where the maternal mortality should be reduced in the framework of the Millennium Development Goals. In this study, the determinants of maternal mortality rate are analyzed in the Kyrgyz Republic regions during 2000-2015 by using static panel data methods fixed effects and random effects. The findings show that there are significant decreasing effects of GDP, number of assistant physicians, births by skilled staff, improved sanitation facilities, and gender wage equality, there are significant increasing effects of health expenditures, medical facilities, and poverty among women on the maternal mortality.

scholarly journals Efektifitas Pelatihan Asuhan Persalinan Normal (APN) Terhadap Peningkatan Pengetahuan Bidan Di Pusat Pelatihan Klinik Sekunder (P2KS) Di Yogyakarta

2019 ◽  
Vol 6 (1) ◽  
pp. 533
Author(s):  
Eko Mindarsih ◽  
Murni Murni
Keyword(s):  
Mortality Rate ◽  
Maternal Mortality ◽  
P Value ◽  
Maternal Mortality Rate ◽  
Post Test

Salah satu indikator yang dapat dijadikan alat untuk mengukur kualitas kesehatan perempuan adalah dengan Angka Kematian Ibu (AKI) atau Maternal Mortality Rate (MMR) AKI di Indonesia adalah 359 per 100.000 kelahiran hidup. Kementerian Kesehatan RI bersama organisasi profesi membentuk Pusat Pelatihan Klinik Sekunder (P2KS) di tingkat Provinsi yang bernaung dibawah JNPK-KR Peningkatan pengetahuan dan keterampilan  bidan  merupakan salah satu upaya untuk menurunkan kematian ibu. Penelitian ini bertujuan mengetahui efektifitas pelatihan Asuhan Persalinan Normal terhadap tingkat pengetahuan bidan di P2KS Propinsi DIY.  Metode penelitian yang digunakan adalah eksperiment. Bentuk desain penelitian ini adalah Quasi eksperimen  design dengan rancangan penelitian pre test dan post test. Nilai pengetahuan sebelum dan sesudah pelatihan pada responden di P2KS DIY terdapat peningkatan sebelum dan sesudah pelatihan sebesar 13, 3 poin. Hasil efektifitas pelatihan terhadap pengetahuan bidan adalah pelatihan Asuhan Persalinan Normal efektif terhadap tingkat pengetahuan responden dengan nilai p value yang diperoleh sebesar 0,000  (p value 0,000 < 0,05). Hasil Penelitian ini dapat disimpulkan bahwa pelatihan asuhan persalinan normal efektif terhadap tingkat pengetahuan responden.

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